Authors:

1. Abhinav Kumar BDS, MDS (Corresponding author)
Senior Lecturer,
Department of Conservative dentistry & Endodontics,
Manavrachna Dental College
Haryana, India

2. Priyanka Sethi Kumar BDS, MDS
Senior Lecturer,
Department of Orthodontics & Dentofacial Orthopedics,
Santosh Dental College & Hospital,
1 Santosh Nagar, Pratap Vihar
Ghaziabad - 201009, U.P..India

3. Sameer Patil BDS, MDS
Professor & Head,
Department of Orthodontics & Dentofacial Orthopedics,
Sinhgad Dental College & Hospital
Pune,Maharashtra

4.Dildeep Bali,
Professor
Department of Conservative dentistry & Endodontics,
Santosh Dental College & hospital,
1,Pratap Vihar,
Ghaziabad,U.P., India


5.Deepa Verma
Professor
Department of Orthodontics,
Santosh Dental College & hospital,
Pratap Vihar, Ghaziabad

Introduction

Cleft of the lip and/or the palate is a congenital birth defect which is characterized by complete or partial clefting of the lip and/or the palate1.The severity of clefting may vary from the trace of notching of the upper lip to complete non-fusion of the lip, primary palate and secondary palate. Facial clefts are seen due to non-fusion of the facial process1.
Approximately one child out of 1000 live births in India is born with this facial deformity.The majority of children born with cleft lip and palate are otherwise normal with no associated syndromes. However a few may have associated disease affecting several systems called syndromic clefts1. Cleft lip and palate occurs more frequently in males and cleft palate alone occurs more frequently in females.

In India , many children are born with this deformity, which have many pshychological implications both for the parent and the child.
A child born with this deformity is subjected to various surgeries at an early age. Surgeons usually take the attitude “Lets get it done now”, however orthodontists say “lets apply a little force and see what the force does over month” This is where nasoalveolar moulding comes into play. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate2.

In the past, fixing a large cleft required multiple surgeries between birth and age 18, putting the child at risk for psychological and social adjustment problems.
The first procedure pulled the lip together, a second improved the position of the lip, another two would be for the nose , followed by a bone graft to close the palate. However ,nasoalveolar molding represents a paradigm shift from the traditional methods of presurgical infant orthopedics. In this both the orthodontist and the surgeon can improve a large cleft in the months before surgery. This helps the surgeon get a better shape of the nose and a thinner scar in only one surgery. A better result in the first surgery means fewer surgeries later in childhood.

History
The state of the art clinical methods and the proposed benefits of presurgical infants orthopedics have changed significantly from those described by the early proponents of the technique. McNeil2 , Hotz and Goninski3, Latham4,Grayson et al 5, emphasized that correction of the nasal cartilage deformity, stretching of the nasal mucosal lining, and the achievement of the non-surgical columella elongation can be combined with the molding of the alveolar process and gingivoperiosteoplasty in patients with clefts and craniofacial anomalies.It has been stated that the combination of nasal and alveolar presurgical infant orthopedic molding has resulted in measurable long term benefits to the patients6.


Goals of Presurgical Nasoalveolar Moulding (PNAM)

1. To improve nasal aesthetics.
2. To Decrease the number of nasal surgical procedures.
3. To Decrease the need for secondary alveolar bone graft in majority of patients.
4. To Ensure no greater growth disturbances than that found in cleft patients under going good traditional treatment.
5. Economically beneficial.

How does NAM work?

The NAM is a palatal appliance that is constructed on an infant’s maxillary cast prepared on a well taken impression.The device consists of an acrylic pelotte attached to the maxillary plate with a wire which lifts the nasal dome. The appliance needs to be modified and activated at weekly basis1.

To start NAM, parents work with an orthodontist. Within the first couple of weeks after birth, babies are fitted with a custom-made molding plate that looks like an orthodontic retainer. The device is attached with a small orthodontic rubberband that is taped to the baby's face.

The molding plate causes no pain and after the first few days the plate usually doesn't bother babies at all; it's an accepted part of their face.
Unlike some older techniques, the molding plate does not push or stretch the delicate tissues; it only helps gently direct the growth of the gums.The baby wears the molding plate 24 hours day, seven days a week, including when they are feeding. The parents change the tape and clean the molding plate daily as needed. After the baby has worn the molding plate for a week, the orthodontist slowly adjusts the shape by sculpturing the plastic. Each adjustment is very small, but it starts to guide the baby's gums as they are growing. Adjustment of the molding plate is done by the orthodontist weekly or every other week depending upon the progress. Each appointment takes 40-60 minutes. Once the cleft gap in the gums is small enough (around one quarter-inch), a post is attached to the molding plate and is inserted in the nostril. This post is then slowly adjusted to lift up the nose and open the nostril.By the time of the surgery, the nose has been lifted and narrowed, the gap in the gums is smaller and the lips are closer together (Figure 1).
A smaller gap means less tension when the surgeon closes the cleft. The benefits of using this presurgical technique have been documented.7

Procedure

1) Evaluation of the patient by interdisciplinary cleft palate team at one or two weeks after birth.

2) Taking impression using Elastomeric impression material, maintaining patent airway

3) Fabrication of molding plate using clear acrylic resin on the maxillary cast. The molding plate is modified at weekly intervals to gradually approximate the alveolar segments and to reduce the size of the intra oral cleft.

4) Construction of nasal stent on the molding plate. It is constructed when the alveolar cleft width is reduced to 6mm.

Figure 1. Nasoalveolar moulding for correction of Unilateral Cleft

Advantages

1) Its ability to guide the alveolar segments into a normal position prior to surgery.

2) Reduction of the cleft gap width ,which facilitates the primary gingivo periosteal closer of the defect8.

3) Combined action of naso alveolar molding plate and non surgical approximation of the lip segments results in a predictable correction of alveolar, nasal cartilage and soft tissue deformities 8.

4) NAM leads to repositioning of the columella and septum from an oblique position into an upright and more midline orientation, which results in improved nasal tip projection and alar cartilage symmetry.

5) NAM leads to bilateral nasal symmetry.

6) Improvement in soft tissue position serves to reduce the complexity of the surgical repair8.

7) Reduction in the need for the alveolar bone grafting thus reducing cost of therapy from birth to adolescence.

Complications

1) Soft tissue breakdown may occur, due to force application that exceeds tissue tolerance8.

2) An area of ulceration may develop intra orally or on the nasal lining where active molding pressure is applied8.

3) If parents fail to properly apply tape and elastics during molding, then the appliance will not be adequately retained during the course of treatment and progress will be lost.

4) Occasionally, the labial surface of the maxillary deciduous central incisor will prematurely emerge through the overlying gingival tissue as a result of pressure from molding plates.

5) If the appliance is not worn or lost, a cleft gap that had been closed early during molding therapy may widen again as the infant places his tongue into the cleft.

Conclusion

Conclusion

PNAM coordinated with primary surgical repair offers the following benefits:

a) Pre surgical reduction of the alveolar cleft gap enables the surgeon to perform gingivo periosteoplasty which reduces the need for secondary alveolar bone grafts.

b) Pre surgical alignment and correction of the deformity in the nasal cartilages minimizes the extent of the primary nasal surgery required , minimizing scar tissue formation and giving more consistent results.

c) PNAM when used in conjunction with a modified surgical approach, allows for a single initial surgical procedure to address the lip -nose­alveolus complex and its deformity, thereby reducing the number and extent of surgeries that a cleft patient will undergo during life time.

d) Long-term studies of NAM therapy indicate that the change in the nasal shape is stable with less scar tissue and better lip and nasal form. [19] This improvement reduces the number of surgical revisions for excessive scar tissue, oronasal fistulas, and nasal and labial deformities. [20]

Refrences available on Request